PROMISe™ ANSI X12 v 5010 OR NCPDP Interactive D.0 or Batch 1.2
Transaction Certification Registration Form

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NOTE: All fields preceded by an asterisk are required fields.
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Organization Information:

* Organization Type:

If you selected Individual Provider or Group Provider for the organization type above, will your transactions be submitted through a billing service/clearinghouse to Pennsylvania Department of Human Services for Medical Assistance ?

* Business Name or Business Last Name:

Business Name 2 or Business First Name:

Business Primary Address

*Address 1:
Address 2:
Mail Stop:
*City:
County:
*State:
*Zip: -

Contact Information:


Primary Contact

*First Name:
*Last Name:
*Phone Number: () - -      Ext: (not required)
Fax Number: () - -
E-Mail Address:

Secondary Contact (if applicable)

First Name:
Last Name:
Phone Number: () - -      Ext: (not required)
Fax Number: () - -
E-Mail Address:

MCO Information:


Select the lines of business that apply:

Enter the plan codes that apply to your MCO:

Transaction Information:


* Select all transaction types for which you need to be certified. Please read the transaction descriptions below carefully before selecting:

837: Inpatient
(Generally refers public or private hospitals, rehabilitation or psych facilities)
837: Outpatient
(Generally refers to: Ambulatory Surgical Centers, Short Procedure Units, Outpatient Psychiatric Centers and others.)
837: Institutional LTC
(Generally refers to private and county nursing homes, ICF/MR, state mental retardation centers)
837: Professional
(Generally refers to physicians, prescribing physicians, medical suppliers, waivers, clinics, ancillary providers and others)
837: Professional Drug
(Generally refers to prescribing physicians and clinics)
837: Dental
(Generally refers to dentists)
270/271: Interactive
(Refers to interactive eligibility verification (EVS). NOTE: You need to register to certify ONLY if you are developing software. Users of certified software need not register.)
270/271: Batch
(Refers to batch eligibility verification - EVS.)
NCPDP D.0
(Refers to online pharmacy billing. NOTE: You need to register to certify ONLY if you are developing software. Users of certified software need not register.)
NCPDP 1.2: Batch
(Refers to batch pharmacy billing)
835 for Any/All Transactions

Software Information:


Use this section to provide information about the primary software you intend to use to submit and receive MA transactions.

Software Information - Primary

*Please select the primary type of software that you intend to use to submit and receive transactions:


*If you will be using transmission software to submit and receive MA transactions please provide the following information regarding the primary software and the software vendor:
(All fields are required)
Software Name:
Software Vendor Name:
Address 1:
Address 2:
City:
State:
Zip: -

Software Vendor Contact Information - Primary

Contact First Name:
Contact Last Name:
Phone Number: () - -      Ext: (not required)
Fax Number: () - -
E-Mail Address:

For Software Vendors only:

Your vendor certification approval status will be posted to the DHS website

Certification Information:


Your Certification Packet will be sent to you via secure email. If you do not have email access, then we will send the Packet via secure email to your Software Vendor

* Select the method in which you would like to receive the certification transaction status results:


Transmissions and Communications:


* Which medium will be used to submit test and production transactions to Pennsylvania Medical Assistance?

* Which medium will be used to receive test and production transaction results from Pennsylvania Medical Assistance?

Note: Transactions sent via the BBS can only receive results via the BBS.


Last Modified: 2/13/2012